Medicare’s Midlife Crisis: Fixing Canadian health care for the 21st century

Canadians like to cling to the notion that our publicly-funded health care system is an example to the rest of the world. But the truth is that many universal access systems around the world perform better than Canada's, and the ballooning cost of delivering even this level of care is not sustainable.

That’s why the Macdonald-Laurier Institute has established itself as a thought leader on Canadian health care – both in drawing attention to the scope of the problem and suggesting reforms for how to fix it. We call this project Medicare's Midlife Crisis.

A looming problem

Canada is facing a demographics squeeze. Aging baby boomers will be retiring from the workforce in growing numbers in the coming years, leaving fewer wage earners to provide the tax revenues necessary to fund the system. As a huge swath of the population gets older they will also require more and more health care services.

The question then becomes: How can provinces prevent the health care system from swallowing up much-needed money for other essential programs such as education and infrastructure?

Reform wanted

Canada’s health care system is not as great as we make it out to be.

"Our system is based on values, and especially values of equity and fairness that apparently transcend any assessment of the quality of care actually received," wrote Brian Lee Crowley, MLI’s Managing Director, in a 2013 commentary.

Our system regularly scores well below comparable countries when it comes to our health-care performance. Canada ranks below average in access to MRIs and at the bottom of the pack in electronic health records and wait times to see a specialist, just to name a few of our shortcomings.

Ideas for change

MLI has produced a range of well-thought out, concrete recommendations designed to improve the delivery of health care services in Canada.

Crowley argues that provinces need to take the lead on instituting reforms. Part of the problem, he says, is that in the early 1990s the federal government attempted to attach strings to the funding it gave the provinces for health care.

This meant that bureaucrats behind desks in Ottawa were left to anticipate the needs of physicians and patients working to deliver care in hospitals and clinics in St. John’s, Newfoundland and elsewhere across the country.

Nor is more money the answer. Escalating federal health transfers from Ottawa during the last decade meant that there was little incentive for provinces to innovate.

Former Saskatchewan finance minister Janice Mackinnon, a New Democrat, argued in a 2013 MLI paper that it’s time to do away with our system of open-ended demand. She wants users of the health care system pay for a portion of the services they utilize, and demonstrates the success of private clinics in her home province, the very cradle of medicare.

Looking elsewhere

Take the examples of Sweden and Switzerland, two countries profiled in a 2013 MLI paper. Author Mattias Lundbäck shows that a series of reforms introduced in those countries have resulted in more efficient practices that point the way to reform. The socialist-leaning Swedes have demonstrated that privatization and user fees for health services are not the work of the devil.

There are similar lessons from systems in Asian countries. A 2015 MLI paper highlights how examining reforms in Asian countries could provide insights for improving Canada’s underperforming system.

Authors Ito Peng and James Tiessen show how reforms in Japan, Taiwan and Korea – including greater competition between hospitals, introducing user fees and putting hospital specialists on salary – have controlled health-care spending while still offering top-quality services. The three countries have also succeeded in addressing aging populations, getting seniors out of hospital and into affordable long-term care.

The Canada Health Act

Many provinces like to hide behind the federal legislation that governs how they must deliver health-care services, the Canada Health Act, as an excuse for doing nothing to reform the system.

In many ways they have a point. In a 2012 paper, authors Jason Clemens and Nadeem Esmail argue the way the CHA is currently written is incompatible with a number of policy options that could help achieve affordable, high-quality care based on proven success in other industrialized countries with universal health care.

But there is more wiggle room within the CHA than you might think.

Lawyer Michael Watts, in a 2013 paper for MLI that clearly lays out what is and isn’t permissible, writes that there is room for provinces to experiment extensively with health care delivery under the Canada Health Act.

MLI’s impact

MLI’s work on health care has been featured in newspapers and other media outlets across the country.

Mackinnon’s MLI paper was cited in media outlets across the country, including CTV, Global, CBC, iPolitics and the Huffington Post. Globe and Mail columnists Jeffrey Simpson and Margaret Wente also discussed her work.

MLI’s health-care authors have also had op-eds appear in the Vancouver Sun, the National Post, the Ottawa Citizen and the Calgary Herald, while Crowley gave a speech on health care at a 2013 conference organized by the Canadian Association for Healthcare Reimbursement in Ottawa.

Other thought leadership

In this “Straight Talk” Q&A, emergency room physician Brett Belchetz lends his perspective from the front-lines of Canada’s health-care system. He argues user fees are needed to discourage some of the people who he sees are abusing the system.